Originally posted August 10, 2015
By Tom Peteet, MD
Mr. J was as close to a typical sixty-year-old patient as possible, wary of doctors and selective in when he took his blood pressure medications. On a sunny Thursday, he woke up nauseated and called an ambulance. During evaluation in the emergency room, his blood pressures reached atmospheric levels (nearly 300 systolic). He began seizing, which soon stopped; he was transferred to the ICU. As the admitting resident, I dutifully went through the potential causes of his elevated blood pressure: medication noncompliance, surreptitious cocaine use, and even the zebra diagnosis of a pheochromocytoma. As for the seizure, I held firm on the diagnosis of PRES, an acronym for posterior reversible encephalopathy syndrome, an under-diagnosed condition of abnormal blood flow to the brain in the setting of high blood pressure.
Mr. J was on course for a typical hospital admission. We would run a battery of tests, determine a singular diagnosis for his problem, and send him home on treatment. The hospital would be reimbursed for his coded diagnoses of hypertension, PRES, seizure, and he would have close follow-up with specialists.
If Mr. J was a typical case, our discussion of costs and appropriateness of testing was not. Despite a resurgence of “cost consciousness” within medicine, the word cost rarely comes up in the ICU. Much of the discourse around cost and of the Choosing Wisely campaign is an effort to avoid unnecessary tests in clearly defined circumstances. However, Mr. J’s case shows us that the vast majority of clinical decisions live in a gray zone of appropriateness. On rounds, the question came down to this: Does he need a brain MRI and angiography (MRA) to “prove” he has PRES? The clinical history seemed to support the diagnosis, and the study could potentially offer limited prognostic information. Also, in the highly improbable scenario the patient did have a small stroke, we would see it on the MRI. What is the value we place on this minimal increase in certainty? According to the Healthcare Bluebook, the cost of both studies is $1,206.
Taking a step back, I wondered about our zeal to “prove” a diagnosis. Physicians so frequently frame clinical questions around diagnostic proof that we forget this is not the only way. Why not frame clinical questions around appropriateness, cost, or even risk-benefit to the patient? Context matters. In settings like the emergency room or ICU, ruling out the worst is highly valued. If Mr. J continued to be stable after a few days, the diagnosis would be PRES by exclusion, and we would all save time and money. Similarly, in one month, if he remained fine, his primary care doctor would not rush to get an MRI. But Mr. J was in the ICU, we needed an answer, and a test offered us the psychological boost we needed.
Mr. J walked out of the hospital five days later on a different regimen of blood pressure medications. He thanked the staff profusely, who in turn, felt they provided excellent care. Each actor behaved rationally: the patient and clinician to get a diagnosis, and the hospital to generate revenue. The system, however, behaved irrationally, to the cost of the public and also the patient. Despite a confirmed diagnosis of PRES, Mr. J will follow up with two specialists to verify the results of other rare causes for high blood pressure, again generating revenue, visits, and a minimal gain in certainty.
As a physician in this structure, I struggle to maintain hope, as thoughtfulness contradicts rationality. For Mr. J, I pushed against getting the MRI because I valued diagnostic utility and system costs over diagnostic accuracy. The system pushed back. The neurologist highly recommended the test, the ICU attending changed over, and the fellow “needed to rule out a mass.” Considering the cost and appropriateness of each test is hard work, and too great a task for one person. While I am skeptical of top-down change, I take solace in the ability of clinicians to think complexly: to weigh accuracy alongside cost, risk, and benefit. In the gray areas of medicine, we as clinicians would do well to ask and wrestle with the question, “What is the price of the certainty we seek?